|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
The published reviews discussed here establish the technical reliability of free tissue transfer, its efficacy in treating complex wounds, the high rate of flap salvage possible with re-exploration (indicating the utility of reliable postoperative monitoring of microsurgical transfers), the possible advantages of early flap closure, and the variety of potential soft tissue complications that can occur at the donor and recipient sites. Future bacteriologic, hematologic, pharmacologic, and flap physiology research should be directed at the problems identified by the analysis of failures and complications. Continued attention to donor site design and management is warranted. Detailed analyses of developing procedures such as functional muscle grafting and free jejunal grafting provide these innovations with appropriate clinical contexts.
Replantation (Table 38-2)
Microsurgery teams from America, Asia, and Europe have published reports describing large numbers of digital replants. Most groups report success rates of 80% to 90% 17-19 or greater. 20,21 More frequent failures occur following crush22,23 and avulsion 17 injuries. Some authors note higher failure rates in pediatric patients,19,23 while others report rare failures in children20 or in patients over 50.
|Vascular compromise requiring re-exploration is a frequent complication. Reported re-exploration rates range from 5% 18 to 26%.13 Different groups report either venous25 or arterial20 occlusion as the most frequently encountered vascular complication. Postoperative cigarette smoking apparently can initiate vascular spasm leading to thrombosis.26 Salvage rates following digit re-exploration can reach 62%20 to 77%,27 but generally are not as high as flap salvage rates following pedicle revisions. Soft tissue complications, infections, and skeletal complications occur rarely. 2,28 All replanted digits develop cold intolerance, 19 but this problem reportedly abates with time. As many as 43% 18 of patients with replanted digits require further surgery to correct functional, sensory, soft tissue and skeletal defects. Steichen29 found that tenolysis could increase the total active motion of selected replanted digits by 37%. Detailed analyses of the indications and results of secondary reconstructive operation may clarify the roles of these procedures in improving the function of replanted digits.|
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